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Depersonalization/Derealization Disorder
DSM-II In DSM-II, this disorder is called Depersonalization neurosis This syndrome is dominated by a feeling of unreality and of estrangement from the self, body, or surroundings. This diagnosis should not be used if the condition is part of some other mental disorder, such as an acute situational reaction. A brief experience of depersonalization is not necessarily a symptom of illness. DSM-III In DSM-III, this disorder is called Depersonalization Disorder Diagnostic Criteria A'''. One or more episodes of depersonalization sufficient to produce significant impairment in social or occupational functioning. '''B. The symptom is not due to any other disorder, such as Schizophrenia, Affective Disorder, Organic Mental Disorder, Anxiety Disorder, or epilepsy. Differential Diagnosis Depersonalization without impairment The symptom of depersonalization, even if recurrent, that does not cause any social or occupational impairment, must be distinguished from Depersonalization Disorder. Other mental disorders In Schizophrenia, Affective Disorders, Organic Mental Disorders (especially Intoxication or Withdrawal), Anxiety Disorders, Personality Disorders, and epilepsy, depersonalization may be a symptom. In such cases, the additional diagnosis of Depersonalization Disorder is not made. DSM-IV In DSM-IV, this disorder is called Depersonalization Disorder Diagnostic Criteria A'''. Persistent or recurrent experiences of feeling detached from, and as if one is an outside observer of, one's mental processes or body (e.g., feeling like one is in a dream). '''B. During the depersonalization experience, reality testing remains intact. C'''. The depersonalization causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. '''D. The depersonalization experience does not occur exclusively during the course of another mental disorder, such as Schizophrenia, Panic Disorder, Acute Stress Disorder, or another Dissociative Disorder, and is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., temporal lobe epilepsy). Differential Diagnosis General Medical Conditions and Substance-Related Disorders Depersonalization Disorder must be distinguished from symptoms that are due to the physiological consequences of a specific general medical condition (e.g., epilepsy). This determination is based on history, laboratory findings, or physical examination. Depersonalization that is caused by the direct physiological effects of a substance is distinguished from Depersonalization Disorder by the fact that a substance (e.g., a drug of abuse or a medication) is judged to be etiologically related to the depersonalization. Acute Intoxication or Withdrawal from alcohol and a variety of other substances can result in depersonalization. On the other hand, substance use may intensify the symptoms of a preexisting Depersonalization Disorder. Thus, accurate diagnosis of Depersonalization Disorder in individuals with a history of alcohol- or substance-induced depersonalization should include a longitudinal history of Substance Abuse and depersonalization symptoms. Other mental disorders Depersonalization Disorder should not be diagnosed separately when the symptoms occur only during a Panic Attack that is part of Panic Disorder, Social or Specific Phobia, or Posttraumatic or Acute Stress Disorders. In contrast to Schizophrenia, intact reality testing is maintained in Depersonalization Disorder. The loss of feeling associated with depersonalization (e.g., numbness) may mimic a depression. However, the absence of feeling in individuals with Depersonalization Disorder is associated with other manifestations of depersonalization (e.g., a sense of detachment from one's self) and occurs even when the individual is not depressed. DSM-5 Diagnostic Criteria A'''. The presence of persistent or recurrent experiences of depersonalization, derealization, or both: # '''Depersonalization: Experiences of unreality, detachment, or being an outside observer with respect to one's thoughts, feelings, sensations, body, or actions (e.g., perceptual alterations, distorted sense of time, unreal or absent self, emotional and/or physical numbing). # Derealization: Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted). B'''. During the depersonalization or derealization experiences, reality testing remains intact. '''C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D'''. The disturbance is not attributable to the physiological effects of a substance (e.g., a drug of abuse, medication) or another medical condition (e.g., seizures). '''E. The disturbance is not better explained by another mental disorder, such as schizophrenia, panic disorder, major depressive disorder, acute stress disorder, posttraumatic stress disorder, or another dissociative disorder. Differential Diagnosis Illness anxiety disorder Although individuals with depersonalization/derealization disorder can present with vague somatic complaints as well as fears of permanent brain damage, the diagnosis of depersonalization/derealization disorder is characterized by the presence of a constellation of typical depersonalization/derealization symptoms and the absence of other manifestations of illness anxiety disorder. Major depressive disorder Feelings of numbness, deadness, apathy, and being in a dream are not uncommon in major depressive episodes. However, in depersonalization/derealization disorder, such symptoms are associated with further symptoms of the disorder. If the depersonalization/derealization clearly preceded the onset of a major depressive episode or clearly continues after its resolution, the diagnosis of depersonalization/derealization disorder applies. Obsessive-compulsive disorder Some individuals with depersonalization/derealization disorder can become obsessively preoccupied with their subjective experience or develop rituals checking on the status of their symptoms. However, other symptoms of obsessive-compulsive disorder unrelated to depersonalization/derealization are not present. Other dissociative disorders In order to diagnose depersonalization/derealization disorder, the symptoms should not occur in the context of another dissociative disorder, such as dissociative identity disorder. Differentiation from dissociative amnesia and conversion disorder (functional neurological symptom disorder) is simpler, as the symptoms of these disorder do not overlap with those of depersonalization/derealization disorder. Anxiety disorders Depersonalization/derealization is one of the symptoms of panic attacks, increasingly common as panic attack severity increases. Therefore, depersonalization/derealization disorder should not be diagnosed when the symptoms occur only during panic attacks that are part of panic disorder, social anxiety disorder, or specific phobia. In addition, it is not uncommon for depersonalization/derealization symptoms to first begin in the context of new-onset panic attacks or as panic disorder progresses and worsens. In such presentations, the diagnosis of depersonalization/derealization disorder can be made if 1) the depersonalization/derealization component of the presentation is very prominent from the start, clearly exceeding in duration and intensity the occurrence of actual panic attacks; or 2) the depersonalization/derealization continues after panic disorder has remitted or has been successfully treated. Psychotic disorders The presence of intact reality testing specifically regarding the depersonalization/derealization symptoms is essential to differentiating depersonalization/derealization from psychotic disorders. Rarely, positive-symptom schizophrenia can post a diagnostic challenge when nihilistic delusions are present. For example, an individual may complain that he or she is dead or the world is not real; this could be either a subjective experience that the individual knows is not true or a delusional conviction. Substance/medication-induced disorders Depersonalization/derealization associated with the physiological effects of substances during acute intoxication or withdrawal is not diagnosed as depersonalization/derealization disorder. The most common precipitating substances are the illicit drug marijuana, hallucinogens, ketamine, ecstasy, and salvia. In about 15% of all cases of depersonalization/derealization disorder, the symptoms are precipitated by ingestion of such substances. If the symptoms persist for some time in the absence of any further substance or medication use, the diagnosis of depersonalization/derealization disorder applies. This diagnosis is usually easy to establish since the vast majority of individuals with this presentation become highly phobic and aversive to the triggering substance and do not use it again. Mental disorders due to another medical condition Features such as onset after age 40 years or the presence of atypical symptoms and course in any individual suggest the possibility of an underlying medical condition. In such cases, it is essential to conduct a thorough medical and neurological evaluation, which may include standard laboratory studies, viral titers, an electroencephalogram, vestibular testing, visual testing, sleep studies, and/or brain imaging. When the suspicion of an underlying seizure disorder proves difficult to confirm, an ambulatory electroencephalogram may be indicated; although temporal lobe epilepsy is most commonly implicated, parietal and frontal lobe epilepsy may also be associated.